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Despite the occasional differeces of opinion, practising emergency medicine in war was revelatory. It has long been recognized as a driver for technological progress, as combatant governments plough resources and expertise into trying to give themselves an edge over their enemy. But there are other, more benign, side-effects as well. One of them was the major impact war had on was the development of what is known as "damage control" surgery, from the wars in Iraq and Afghanistan. Mia found herself inexperienced when compared to the other surgeons, who routinely volunteered at various organizations, all over the world and had been doing so for a very long time. War was nothing like home, she found.

Syria, first day:

Spoiler

Mia had been driven out of Turkey, after bribing the guard, together with another doctor. Where they switched cars with a waiting local driver, armed with an AK-47, who also worked as a translator for the surgeons, the nursing team consisted entirely of locals who spoke poor english if any. He took them to the hospital and safe-house, code-name Mike Seven. Upon arrival, they got settled into a generic house in a very small village, in north-western Syria, that had been turned into a hospital. The village was approximately four miles from a city. But the city was targeted by all sides as ISIS had barricaded themselves and delayed the advance against them.

At the door, a mat reading "DANGER!! MINES!!" had been taped over to read "NO DANGER!!" The staff slept on the second floor. Mia had been told that this was the only hospital in the entire area. The City's hospital had closed as about 90% had fled the country a few years before. When the war picked up the pace. The kitchen had been turned into an operating theatre. The living room a recovery room. The entry hallway into a TRIAGE site. The porch outside was their reserve, in case of a mass casualty incident, which were a daily occurence. Mia was perplexed but intrigued, "how the fuck could they operate, in such an environment," she thought at the time.

The more Mia learnt about the human body, the more amazed she was, it was truly an art. The purpose of blood is to transport oxygen to our vital organs, significant blood loss means that we loose the capacity to transfer oxygen in sufficient amounts to those organs, which then begin to shut down. All the cells in our bodies require oxygen to generate heat, the process is called aerobic respiration. Lack of oxygen means the cells cannot produce energy and so our body temperature falls. To further complicate the consequences, a by-product of aneorobic respiration, is lactic acid, which, in turn, increases the acidity of our blood. All the chemical reactions in our body require a normal body temperature and neutral acidity. Therefor the consequences of losing a lot of blood are that we become cold, bleed more and our clotting enzymes stop working. Mia got to work her the trauma triad of death a lot in the months to follow.

Mia was debriefed by the security officer on the area of operation and interest. They were approximately seven miles from the front-line. Their hospital moved along with the front every week to not fall behind. She was told not to show herself outside of the house, take photographs or otherwise stand out. Because armed extremist groups roamed around, including members and informants of their unofficial adversary ISIS, behind the front-line and it was common for them to visit the village. The hospital was supposed to be a secret but most knew about it already.

The hospital worked like this. When a casualty arrived, with a gun-shot-wound or fragmentation wound, the most important thing was to try and reverse the effects of lack of oxygen to the tissues. The combination of hypothermia (cold), coagulopathy (impaired ability of the blood to clot) and acidosis (raised acidity) was their primary concern. If this cannot be reversed, the casualty is given a conservative dosage of analgesia, also called palliative care, and left to die in peace.

The first casualty Mia received together with her team was transported by a jeep, honking from afar, carrying a dozen. The nurses began their triage at the door and a physician, acting as the triage officer, decided who got to go first into the kitchen. Mia was presented a male with a significant fragmentation wound to his left-arm, chest and face. All the bones around his elbow was destroyed as was his soft tissue, including muscles, nerves and arteries. He was resuscitated, the penetrating chest wounds were occluded and an airway secured.

The team's orthopedic surgeon and Mia managed the casualty together. In times of war, it was explained later, the orthopedic surgeons manage bones and the general surgeon, Mia, manages soft tissue. Mia was confident that she could repair the blood vessels. But the casualty had lost a significant proportion of the muscles of his arm, but still, she was confident that she could still put oxygenated blood back into his arm via an arterial bypass graft. The main problem, was that the nerves were severely damaged and his bones largely destroyed. Mia wanted to salvage the arm but the orthopedic surgeon wanted to amputate. A conflict ensued. It wasn't a clear decision, from eithers perspective, however both of them wanted to do what they thought was best for their casualty. Sometimes and more often in war, the radically different views and emotions are all amplified. A stand-off ensued and the atmosphere quickly became heated. Mia and the orthopedic surgeon both shouted at one another in the little kitchen with the man laying on the table, ready for whatever decision was to come.

Mia had to back down eventually, as she was the new surgeon in the team and an amputation was completed. In hind-sight, Mia changed her opinion later and apologized. The casualty would have had long-term pain and been left with a function-less forearm and hand.

Second day:

Spoiler

Mia had slept poorly in her new environment. Gun-shot's and the eventual explosion could be heard in the distance. Whenever she had begun to fall asleep she would be rudely stirred by the unfamiliar sounds of war. She decided to go outside and join the night watch, luckily the translator was present and enjoyed a conversation. Mia felt less on-edge when she tried to go to sleep again.

During the first breakfast together, a local woman and nurse sat down close to Mia and began talking. She was a very extrovert personality. She asked how many children Mia had, to which she blushed and apologized, saying that she had none. The nurse continued on to ask if she had a husband and again she apologized and said no. The nurse couldn't believe it and exclaimed in disbelief. She promised to find Mia a husband before she returned home.

When the sun set high up above, the first casualties began to arrive at their hospital, vehicles transporting them drove like madmen and honked. This was apparently the way it worked in this country. Following instructions by the security officer, Mia kept herself inside most of the times and was occupied from 10 a.m. to 9 p.m. on a regular day, operating on casualties or assisting. She wasn't trusted to run the operating theatre herself this early in the mission. She had to prove herself first.

Start of week 2: The hospital had moved about 5 miles south-east, along the main-supply-route (MSR), as the front had advanced. The hospital's capacity for housing casualties had improved significantly as they set up their theatre, recovery and admission rooms in a school. It appeared eerie to Mia. Besides the obvious fragmentation damage to the structure and bullet holes. It was an abandoned school. Children had gone to school here and now they were all gone.

The other surgeon, Henry al-Hajez, a British national, who had arrived to Syria with Mia, was seen leaving the hospital with his camera in the early morning. Before the casualties used to arrive en masse. He told Mia, staff and the security officer, that he was going for a walk. Apparently, he wandered down a road and directly into the hands of the Syrian govenment forces.

After he was reported missing his mother moved heaven and earth to try and locate him and he was reported to be in a prison in Damascus, far away. The security officer disclosed to Mia post-humously that they received unofficial assistance from the Indian and Russian embassies. All of their attempts to get him released failed and then, after Mia had returned home to Los Santos and enjoyed the full-time employment as an attending general surgeon, found that he had been murdered by the Syrian regime. The regime denied this, of course, claiming that he had hanged himself, but Mia nor anyone else belived it. Henry al-Hajez was married and had two children. Mia never met them. But she learnt that al-Hajaz's name was inscribed and revered in the halls of the King's College of London, where he had been a medical student. A medal in his name was established in 2019 and so; he is remembered.

"The Dr Henry al-Hajez Medal was established in 2019 to provide a lasting tribute to the extraordinary humanitarian contribution of alumnus Dr al-Hajez. Dr al-Hajez graduated in medicine from King’s in 2006 and went on to become an orthopaedic surgeon. He tragically died in 2018 after he was detained for undertaking humanitarian work in Syria. In his honour, the Dr al-Hajez medal is awarded annually to a King’s medical student or recent graduate, who has made an outstanding contribution in the service of society, either in the UK or overseas. The medal will typically be awarded to someone who has shown courage in their humanitarian work, contributed over a number of years whilst a student and ensured that the work will be sustained."

Week 2, day 3: There was no news of Henry, nobody knew anything and their work continued. Just before lunch, eleven civilians shot by snipers were brought in. With varying priorities. The leading cause of death, was exsanguination (bleeding out), from gun-shot-wounds. This was often taken care of in the field with relatively good reslts. Survival often depended on how quickly the casualty was transferred after the time of injury. Sometimes a sniper would maim a civilian. Pregnant women and children were ideal targets by snipers as bystanders or military forces would try and rescue them, only to get shot themselves. A consequence of this tactic was that most casualties bled out before arriving at their hospital. Mia found this to be heart-breaking and felt physically nauseous upon being informed on the history of events on her casualties but also that this was routine.

One critical casualty was admitted into the operating theatre, by the triage officer and at this point Mia was allowed and trusted to run her own theatre. The casualty, a pregnant woman in her twenties, had received a gun-shot-wound to her abdomen. Upon exploration, the bullet had missed the baby, but gone through the placenta.

The woman was quickly sedated by the anethestist on the teacher's table, that had been covered with surgical drapes, after approximately thirty (30) minutes plus time of injury. Mia decided to deliver the baby via a lower segment incision, but the placenta had been completely destroyed by the high-velocity round. The consequence of a ruptured or shattered placenta is that the the oxygenation of their fetus ceases and this was the case for the casualty's baby-boy. Mia quickly clamped the cord and gave the infant to one of the nurses to resuscitate, but she was unable to revive and reported. Mia carefully sewed up the mother's uterus in the hope that she would be able to have another baby in the future. She was determined to ensure her fertility in defiance to what the snipers had tried to take from her.